Fall Protection Site Assessment Checklist Form
Complete this checklist to assess fall protection hazards, equipment, and conditions at the workplace site.
Site Name/Location
*
Date of Assessment
*
-
Month
-
Day
Year
Date
Assessor Name
*
First Name
Last Name
Observed Fall-Protection Hazards
*
Unprotected edges/openings
Improper ladder use
Inadequate guardrails
Missing fall arrest systems
Other
Fall-Protection Equipment/Anchorage Status
*
All equipment/anchorage in good condition
Some equipment/anchorage needs repair
Equipment/anchorage missing or unsafe
Environmental Conditions at Time of Assessment
*
Clear/dry
Wet/slippery surfaces
Windy conditions
Obstructed walkways
Other
Overall Fall Risk Level
*
Low
Medium
High
Required Corrective Actions
*
Assessor's Comments
Follow-up Date (if applicable)
-
Month
-
Day
Year
Date
Additional Notes
Submit Assessment
Should be Empty: